Lister, Carbolic Acid & Alcohol– have we come full circle?

I recently received my annual Nurses’ League Journal from my training hospital, Kings College Hospital, London – the same one featured in one of my previous blogs on the TV show, ’24 hours in Emergency’. The League is essentially the ‘old girls’ association which we joined on completion of our training. The journal is full of news of us ‘old girls’, the reunions that have taken place and general news of the hospital’s activities. The journal usually features an aspect of the hospital’s history, a South London institution since the early 1800s. In this edition, the story of the eminent 19th century surgeon, Joseph Lister was featured. He is widely regarded as transforming surgery into a practice governed by science due to his pioneering work on antisepsis.

Joseph Lister

Joseph Lister

Why am I telling you all this? Well, at the time I was reading about Lister in the journal, I was also editing the chapter on asepsis and infection prevention for the forthcoming second edition of ‘Perioperative Nursing: An Introductory Text’, due for release in May 2016 at the ACORN Conference in Hobart. I was interested to read about Lister’s infection control practices in 1867 and how they contrast with our present day practice. He, like many of his contemporaries, were appalled and puzzled by the high rates of surgical site infections (SSI) which often led to post op death.
It was the work of French chemist of Louis Pasteur’s that influenced Lister’s thinking about what might cause infection. Pasteur had postulated that fermentation of wine and milk was due to bacteria found floating in the air and not just the air itself that caused infection, as had been traditional thinking. Armed with this light bulb moment, Lister’s next step was to experiment with a variety of antiseptic agents which he thought might kill the bacteria that infected surgical wounds. He settled on carbolic acid (phenol) after hearing about its success in cleaning up the city’s stinking sewers. He introduced it into his operating theatre at the Glasgow Royal Infirmary, Scotland, which must have been a most uncomfortable place to work as he sprayed carbolic acid over the operative field (and all the assistants) continuously during surgery and soaked dressings in the solution. His breakthrough moment came when treating a compound tibial fracture in an 11 year old boy, James Greenlees using dressings soaked in carbolic acid. After a few days there was no evidence of the usual infection that blighted such procedures and James made a full recovery.

Lister spraying carbolic acid during surgery

Lister spraying carbolic acid during surgery

Lister continued this type of wound dressing on other surgical patients and his post-operative infection rates dropped dramatically. If Lister had access to the internet, news of this dramatic breakthrough in infection prevention would have spread like wildfire and perhaps been accepted a little sooner, but it was two years before he published a number of articles about his work in the Lancet medical journal. Even then his results were viewed with a degree of scepticism, by many colleagues, particularly in London and it would be another 20 years of further experimentation before the medical profession accepted Lister’s theory and practical application of antisepsis.
Lister carried out much of his research at my old training hospital, King’s College, where he was appointed Chief of Surgery in 1877 and confronted many of his fiercest critics. The hospital had prohibited open surgery into joints due to the high risk of infection, but Lister believing in his antisepsis methods bucked the system (after all he was the boss!), forging ahead with his work, which eventually paid off, laying the foundations for our modern understanding of antisepsis and ultimately aseptic technique.

operating theatre at Kings College Hospital, London

operating theatre at Kings College Hospital, London

Even though we have come a long way since Lister in our understanding of antisepsis and infection prevention, SSIs are still of great concern in the 21st century. Hand washing continues to be a vital strategy in the fight to reduce the risk of infection and what struck me about surgery in Lister’s era, the late 19th century was the use of alcohol as a hand hygiene product. Three to five minutes pre-operative cleansing of the hands using 90% ethanol was common practice amongst surgeons of that era. The efficacy of alcohol to kill microorganisms on the skin has therefore been known for sometime and with the recent introduction of alcohol based surgical scrub solutions (ABSS) in many Australian operating theatres, it feels like we are back to the future!
Moving to ABSS will require a change of culture in our operating theatres – the ritual of the surgical scrub is one which many instrument nurses may be somewhat reluctant to give up – that five minutes or so at the sink was good thinking time when you could gather your thoughts and prepare yourself mentally for the procedure ahead. Replacing that with a 90 second rub with alcohol based product will not come easy to some! For the surgeons too, it is a big change, although having witnessed some surgeons undertake what passes for a surgical scrub by a momentary waving of hands under running water, an application of alcohol will at least kill a few bugs!

Alcohol based surgical scrub

Alcohol based surgical scrub

Many of you have perhaps already been involved in trialling the variety of ABSS products that medical companies are now clamouring the sell us. It’s big business for them! What’s important is to ensure that we make choices based on available evidence of the efficacy of the products and not the hard sell and promises of the company reps. There are many different products on the market –some containing differing percentages of alcohol and those that combine alcohol with other antimicrobial products eg chlorhexidine. Which one to choose? Don’t be afraid to ask the reps for research evidence to back up their claims, but it’s also important to do your own independent research – there is plenty out there and World Health Organisation has some good resources too.
It seems we have come a full circle in the 150 years since Lister first laid the foundations of infection prevention with the introduction of ABSS in the 21st century. It will become one more strategy we can use to reduce the risk of SSIs that continue to be a cause of morbidity and mortality in our hospitals.
Let us know if you are using ABSS in your workplace and how this new procedure is being received.
Bye for now
Menna